[Effects of new minimum volume standards in visceral surgery on healthcare in Brandenburg, Germany, from the perspective of healthcare providers]

BACKGROUND

The legally prescribed minimum volume standards for complex esophageal and pancreatic surgery have been increased or will increase in 2023 and 2025, respectively. Hospitals not reaching the minimum volume standards are no longer allowed to perform these surgeries and are not entitled tor reimbursement.

OBJECTIVE

The study aims to explore which effects are expected by healthcare professionals and patient representatives and what possible solutions exist for Brandenburg, a rural federal state in northeast Germany.

MATERIAL AND METHODS

In this study 19 expert interviews were conducted with hospital employees (head/senior physicians, nursing director), resident physicians and patient representatives between July 2022 and January 2023. The data analysis was based on content analysis.

RESULTS

Healthcare professionals and patient representatives expect a redistribution into a few clinics for surgical care (specialized centres); conversely more clinics that do not (no longer) perform the defined surgeries but could function as gatekeeping hospitals for basic care, diagnostics and follow-up (regional centres). The redistribution could also impact forms of treatment that are not directly defined within the regulation for minimum volume standards. The increased thresholds could also affect medical training and staff recruitment. A solution could be collaborations between different hospitals, which would have to be structurally promoted.

CONCLUSION

The study showed that minimum volume standards not only influence the quality of outcomes and accessibility but also have a multitude of other effects. Particularly for rural regions, minimum volume standards are challenging for access to esophageal and pancreatic surgery as well as for communication between specialized and regional centres or resident providers.

How can clinicians choose between conflicting and discordant systematic reviews? A replication study of the Jadad algorithm

Introduction

The exponential growth of published systematic reviews (SRs) presents challenges for decision makers seeking to answer clinical, public health or policy questions. In 1997, an algorithm was created by Jadad et al. to choose the best SR across multiple. Our study aims to replicate author assessments using the Jadad algorithm to determine: (i) if we chose the same SR as the authors; and (ii) if we reach the same results.

Methods

We searched MEDLINE, Epistemonikos, and Cochrane Database of SRs. We included any study using the Jadad algorithm. We used consensus building strategies to operationalise the algorithm and to ensure a consistent approach to interpretation.

Results

We identified 21 studies that used the Jadad algorithm to choose one or more SRs. In 62% (13/21) of cases, we were unable to replicate the Jadad assessment and ultimately chose a different SR than the authors. Overall, 18 out of the 21 (86%) independent Jadad assessments agreed in direction of the findings despite 13 having chosen a different SR.

Conclusions

Our results suggest that the Jadad algorithm is not reproducible between users as there are no prescriptive instructions about how to operationalise the algorithm. In the absence of a validated algorithm, we recommend that healthcare providers, policy makers, patients and researchers address conflicts between review findings by choosing the SR(s) with meta-analysis of RCTs that most closely resemble their clinical, public health, or policy question, are the most recent, comprehensive (i.e. number of included RCTs), and at the lowest risk of bias.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01750-2.

This is the first empirical study to replicate Jadad algorithm assessments to evaluate discordance across systematic reviews.

In 62% (13/21) of cases, we were unable to replicate the Jadad algorithm assessment and ultimately chose a different systematic review than the authors.

When assessing systematic reviews using the Jadad algorithm, some steps of the Jadad algorithm were vague in description, making it difficult to operationalise, interpret, and use.

The Jadad algorithm has several limitations as it does not account for the last literature search of the systematic review and publication recency of included trials.

To assess discordance in the absence of an algorithm, we recommend decision makers consider relevance (objectives that most closely resemble their clinical question), recency (dates of search), comprehensiveness (most trials), and risk of bias (lowest risk of bias SR) when choosing one systematic review across multiple.

An algal enzyme required for biosynthesis of the most abundant marine carotenoids

Fucoxanthin and its derivatives are the main light-harvesting pigments in the photosynthetic apparatus of many chromalveolate algae and represent the most abundant carotenoids in the world's oceans, thus being major facilitators of marine primary production. A central step in fucoxanthin biosynthesis that has been elusive so far is the conversion of violaxanthin to neoxanthin. Here, we show that in chromalveolates, this reaction is catalyzed by violaxanthin de-epoxidase-like (VDL) proteins and that VDL is also involved in the formation of other light-harvesting carotenoids such as peridinin or vaucheriaxanthin. VDL is closely related to the photoprotective enzyme violaxanthin de-epoxidase that operates in plants and most algae, revealing that in major phyla of marine algae, an ancient gene duplication triggered the evolution of carotenoid functions beyond photoprotection toward light harvesting.

[Limited Data for Second Opinion Programs: a Systematic Review]

Objective: According to a new legislation that will be set up in 2016, patients with an indication for elective surgery have the right to obtain a second opinion. The Federal Joint Committee has to provide a list of indications where this legislation will come into effect. The aim of this systematic review is to summarize available data on second opinion programs and to analyze the indications that should be covered by the new legislation. Methods: Medline, Embase, Proquest and Google scholar were searched for relevant studies in March 2015. To be included, primary studies had to deal with a surgical, orthopedic or gynecological elective procedure, and report agreement between first and second opinion. Study selection and critical appraisal were carried out by 2 reviewers independently. Disagreements were resolved by discussion. Data were extracted and analyzed. Results: In total, 17 studies fulfilled all inclusion criteria. All but one study were from the United States and only 3 studies have been published since 2000. The majority of studies were published in the 70 s and 80 s. Overall, agreement rates varied substantially from 43.0% to 95.5%. Most studies dealt with hysterectomy (n=6), cholecystectomy (n=5) and knee surgery (n=5). Median agreement rates for these procedures were 77.9% (range: 72.7-92.0%), 92.0% (88.2-95.5%) and 85.6% (76.1-93.5%), respectively, in obligatory second opinion programs and 63.0% (58.0-66.7%) and 87.0% (78.0-87.9%) in voluntary second opinion programs. Not enough data were available for knee surgery. Conclusions: Current data on second opinion programs is very limited. There is no data for Germany. Following this, it remains unclear which data or evidence will be used by the Federal Joint Committee to set up the new legislation. However, the findings suggest a potential for second opinion programs. They should be investigated in controlled trials in future.

[Sigmoid colon diverticulitis : Treatment modalities 2011-2013]

INTRODUCTION

Diverticulosis is a relevant disease in Germany with a prevalence of over 60 % in patients aged ≥70 years. The S2k guidelines for the treatment of diverticulosis were recently published. Systematic epidemiological data on treatment modalities do not exist.

METHODS

Analysis of in-hospital treatment modalities for diverticulosis based on data from the Federal Office of Statistics.

RESULTS

Approximately 130,000 inpatient cases of diverticulosis are treated in Germany per year. Approximately 25 % undergo surgery and of these slightly under 50 % (12,000 procedures) are carried out by laparoscopy. The complication rates are 18 % in a best case scenario and up to 85 % in a worst case scenario. A stage-adjusted classification of treatment modalities based on data from the Federal Office of Statistics is currently practically impossible.

CONCLUSION

To enable stage-adjusted epidemiological analysis of diverticulosis, a standardized and transparent documentation system enabling systematic analysis is necessary, which does not currently exist (e. g. ICD 10 coding); moreover, information on conservative and interventional treatment options are not included in the operations and procedures key (OPS) coding system.

[Current status of total hip and knee replacements in Germany - results of a nation-wide survey]

BACKGROUND

Total hip and knee replacements are very frequently performed operative procedures in German hospitals. Despite the high number of cases, only few data on treatment procedures of the clinical routine and their impact on postoperative length of stay and clinical outcome are available. The aim of our survey was to gain detailed insights of the treatment procedures in patients scheduled for elective hip or knee replacement in order to extract recommendations for improving patient care.

METHODS

In a nation-wide survey, we asked leading physicians of 694 trauma surgery and orthopaedic surgery departments and their corresponding colleagues in the departments of anaesthesia for treatment procedures including the process of patient admission, surgical techniques, postoperative analgesia, discharge management and follow-up. We used a multiple linear regression for analysing variables impacting on the postoperative length of stay.

RESULTS

Altogether, 303 replies representing 31.8 % of the contacted hospitals could be evaluated. For hip arthroplasty, the anterolateral approach was most commonly chosen. For knee arthroplasty, the parapatellar approach was most frequently used. Tourniquet and wound drainage (mostly removed on the second postoperative day) were widely used with more than 90 %. The avoidance of wound drainage was associated with a lower postoperative length of stay for patients following total hip or knee replacement. Only 70 % of the German departments followed up their patients after discharge checking especially the range of motion of the artificial joint replacement.

CONCLUSION

The treatment procedures for elective hip and knee replacement are very heterogeneous in German hospitals. The quality of the clinical outcome cannot be related to a single procedure; in fact the choice and complementary interaction of interventions are essential for improving patient care. These results provide first important evidence to which extent organisational structures and treatment procedures affect patient care and length of stay. Therefore, the analyses show relevant indications for an optimised standard in patient care.

[Differences in the use of health care services--is everything unethical?]

BACKGROUND

Regional differences in the use of health services have been known for several decades. This variability is often overall regarded as undesirable in discussions and ethical-moral argumentation takes place. The description and analysis of this variability and the underlying causes are the subject of numerous investigations in various health care systems.

RESEARCH QUESTION

The purpose of this research was to determine which causes can the current health care situation be attributed to and which approaches exist to counteract undesirable variability.

MATERIAL AND METHODS

On the basis of a selective literature search, an overview on the identification of variations in surgical care as well as a presentation of possible causes and solution approaches were created.

RESULTS

Numerous factors influencing the decision-making process regarding surgical interventions could be identified. These can be patient-related, disease-/intervention-related, physician-related, or system-related and are partially linked with each other. The optimal strategies to minimize variability in health care are still unclear. Scientific evidence to assess the benefit and risk of an intervention, physician's attitudes and preferences as well as the involvement of patients in the decision-making process, however, seem to be important starting points.

CONCLUSION

The description of regional differences is an important step toward provision of evidence-based and tailored health care. Differences in health care provision and especially regionally varying high intervention rates are not per se problematic. Whether a patient receives an intervention or not should, however, not depend any more on where he or she lives and which physician is being consulted, but on his or her individual medical condition or preferences. Target group-oriented evidence-based information can help to minimize undesirable variability.

[Patient safety in health service research]

Patient safety is an essential quality criterion for good medical care. A main aim of patient safety interventions is the prevention and/or reduction of adverse events. Various approaches are available for this. The multidisciplinarity in health services research as well as the wide range of methods and topics leads to the fact that health services research is predestined to deal with many of the resulting research questions and with respect to the complexity.

Adherence-enhancing interventions for highly active antiretroviral therapy in HIV-infected patients - a systematic review

OBJECTIVES

The objective of this systematic review was to evaluate the effectiveness of adherence-enhancing interventions for highly active antiretroviral therapy (HAART) in HIV-infected patients in developed countries.

METHODS

A systematic literature search was performed (January 2001 to May 2012) in EMBASE, including MEDLINE records, CENTRAL and PsycInfo. Trials meeting the following predefined inclusion criteria were included: adult patients with an HIV infection treated with HAART, an intervention to enhance patient adherence, adherence as the outcome, clinical outcomes, randomized controlled trial (RCT), article written in English or German, patient enrolment after 2001, and trial conducted in World Health Organization (WHO) stratum A. Selection was performed by two reviewers independently. All relevant data on patient characteristics, interventions, adherence measures and results were extracted in standardized tables. The methodological trial quality was evaluated by two reviewers independently. All discrepancies were discussed until a consensus was reached. A meta-analysis could not be performed because of the heterogeneity of trials.

RESULTS

In total, 21 trials fulfilled all inclusion criteria. Of 21 trials, only one that examined motivational interviewing for alcohol-dependent patients showed statistically significant results for adherence rates and viral load in favour of the intervention. One trial showed a statistically significant clinical effect of the intervention; however, inconsistent results were presented for adherence depending on the underlying adherence definition. The results of the remaining 19 trials were not statistically significant or were conflicting for adherence and/or clinical outcomes. However, the methodological trial quality was low.

CONCLUSIONS

It is not possible to definitively assess the effectiveness of adherence-enhancing interventions. However, it appears that most adherence interventions have no effect.

Bacterial community dynamics during in-situ bioremediation of petroleum waste sludge in landfarming sites

In-situ bioremediation of petroleum waste sludge in landfarming sites of Motor Oil Hellas (petroleum refinery) was studied by monitoring the changes of the petroleum composition of the waste sludge, as well as the changes in the structure of the microbial community, for a time period of 14 months. The analyses indicated an enhanced degradation of the petroleum hydrocarbons in the landfarming areas. A depletion of n-alkanes of approximately 75-100% was obtained. Marked changes of the microbial communities of the landfarms occurred concomitantly with the degradation of the petroleum hydrocarbons. The results obtained from terminal restriction fragment length polymorphism (T-RFLP) analysis of polymerase chain reaction (PCR) amplified 16S rRNA genes demonstrated that bacteria originating from the refinery waste sludge and newly selected bacteria dominated the soil bacterial community during the period of the highest degradation activity. However, the diversity of the microbial community was decreased with increased degradation of the petroleum hydrocarbons contained in the landfarms. T-RFLP fingerprints of bacteria of the genera Enterobacter and Ochrobactrum were detected in the landfarmed soil over the entire treatment period of 14 months. In contrast, the genus Alcaligenes appeared in significant numbers only within the 10 month old landfarmed soil. Genes encoding catechol 2,3-dioxygenase (subfamily I.2.A) were detected only in DNA of the untreated refinery waste sludge. However, none of the genes known to encode the enzymes alkane hydroxylase AlkB, catechol 2,3-dioxygenase (subfamily I.2.A) and naphthalene dioxygenase nahAc could be detected in DNA of the landfarmed soils.

Intraoperative and early postoperative gastric intramucosal pH predicts morbidity and mortality after major abdominal surgery

The present study was undertaken to investigate the correlation between the intraoperative and postoperative gastric intramucosal pH (pHi) with important perioperative variables and to explore any potential relationship of the measured pHi with the patients' postoperative course. A prospective study was carried out in a group of 48 patients who underwent major abdominal operations over an 8-month period at St. John Hospital and Medical Center. An automated air tonometer was used for gastric pHi monitoring. Twenty-eight elective and 20 emergency abdominal operations were performed in 23 men and 25 women. Twenty-six patients (54%) required postoperative hospitalization in the Intensive Care Unit (ICU). Seventeen patients (35%) developed early postoperative complications. The non-ICU and ICU mortality rates were 4.5 and 19.2 per cent respectively. The mean intraoperative pHi (pHiOR) and postoperative pHi (pHiPO) ranged between 7.03 and 7.58 (7.38+/-0.12) and 6.89 and 7.56 (7.35+/-0.12) respectively (mean +/- standard deviation). There was a significant decrease of the gastric pHi at the first hour intraoperatively compared with the pHi after induction to anesthesia (7.44 vs 7.38+/-0.14, P < 0.001). Patients who underwent emergent abdominal procedures were characterized by lower pHiOR and pHiPO values (7.43+/-0.08 vs 7.30+/-0.13 and 7.39+/-0.84 vs 7.30+/-0.15, P < 0.001 and P < 0.05). Similarly patients who required surgical ICU admission had significantly lower pHiOR and pHiPO measurements (7.3+/-0.12 and 7.28+/-0.12) compared with the rest (7.46+/-0.06 and 7.43+/-0.06; P < 0.001). Overall, lower pHiOR and pHiPO values were associated with the occurrence of postoperative complications (P < 0.001), the postoperative mortality (P < 0.001), the requirement for postoperative mechanical ventilator (P < 0.001) and its duration (P < 0.001), longer ICU stay (P < 0.001), and prolonged hospitalization (P < 0.05). Evidence of intraoperative and early postoperative gastric mucosal ischemia (pHiOR and pHiPO < or = 7.32) was observed in 12 (25%) and 15 (31%) patients respectively. The incidence of postoperative complications and the mortality rate were higher in this group of patients (P < 0.001). At a cutoff point of 7.32 gastric pHiOR gave a sensitivity of 69 per cent and specificity of 97 per cent for predicting postoperative complications as well as a sensitivity and specificity of 67 per cent and 81 per cent for predicting death. Intraoperative and early postoperative gastric pHi is a reliable predictor of patient outcome after major abdominal operations. Splanchnic ischemia may play an important role in determining early complications and survival; therapy guided by the gastric pHi might improve outcome.

The effects of triiodothyronine augmentation on antithrombin III levels in sepsis

Sepsis and multisystem organ failure are often associated with disseminated intravascular coagulation and consumption of coagulation inhibitors such as antithrombin III (ATIII). The "sick euthyroid syndrome" is also seen in association with significant illnesses and consists of decreased levels of circulating triiodothyronine (T3). We evaluated whether T3 supplementation would affect ATIII levels in septic rats. Thirty Sprague-Dawley rats were divided into three groups: sham laparotomy (S) plus saline, cecal ligation and puncture (CLP) plus saline, and CLP plus T3 (3 ng/hour) via an osmotic minipump. Twenty-four hours after laparotomy blood was drawn, and T3 and ATIII levels were then compared with baseline values. T3 supplementation partially negated the sepsis-induced decrease in circulating T3 levels. The levels are expressed as percentage change from the levels before surgery (S, -12.9 +/- 3.1; CLP, -60.0 +/- 5.3; CLP + T3, -34.9 +/- 4.3; mean +/- standard error; P < 0.05). T3 supplementation also statistically changed the percentage difference in ATIII levels toward the control (S, 9.6 +/- 2.8; CLP, -37.9 +/- 5.4; CLP + T3, -16.0 +/- 4.5; mean +/- standard error; P < 0.01). T3 supplementation reduced the sepsis-induced decrease in ATIII levels. Whether this was accomplished by decreased consumption or increased production of ATIII via the direct anabolic effect of T3 on acute-phase protein synthesis in the liver is unknown and warrants further investigation.

Chromosomal integration of tcb chlorocatechol degradation pathway genes as a means of expanding the growth substrate range of bacteria to include haloaromatics

The tcbR-tcbCDEF gene cluster, coding for the chlorocatechol ortho-cleavage pathway in Pseudomonas sp. strain P51, has been cloned into a Tn5-based minitransposon. The minitransposon carrying the tcb gene cluster and a kanamycin resistance gene was transferred to Pseudomonas putida KT2442, and chromosomal integration was monitored by selection either for growth on 3-chlorobenzoate or for kanamycin resistance. Transconjugants able to utilize 3-chlorobenzoate as a sole carbon source were obtained, although at a >100-fold lower frequency than kanamycin-resistant transconjugants. The vast majority of kanamycin-resistant transconjugants were not capable of growth on 3-chlorobenzoate. Southern blot analysis revealed that many transconjugants selected directly on 3-chlorobenzoate contained multiple chromosomal copies of the tcb gene cluster, whereas those selected for kanamycin resistance possessed a single copy. Subsequent selection of kanamycin resistance-selected single-copy transconjugants for growth on 3-chlorobenzoate yielded colonies capable of utilizing this carbon source, but no amplification of the tcb gene cluster was apparent. Introduction of two copies of the tcb gene cluster without prior 3-chlorobenzoate selection resulted in transconjugants able to grow on this carbon source. Expression of the tcb chlorocatechol catabolic operon in P. putida thus represents a useful model system for analysis of the relationship among gene dosage, enzyme expression level, and growth on chloroaromatic substrates.

Effect of biocompatibility of hemodialysis membranes on serum albumin levels

Hypoalbuminemia in end-stage renal disease is a marker of high morbidity and mortality. In some patients, the cause of low serum albumin levels is easily identified and therefore treatable, but in many patients, the cause is not clear. We studied the effect of changing the dialysis membrane from a bioincompatible to a biocompatible membrane on serum albumin level. Stable hemodialysis patients dialyzed with cuprammonium membranes who had serum albumin levels less than 3.5 g/dL were switched to the more biocompatible membrane, polysulfone. Serum albumin levels increased from 3.22 +/- 0.037 to 3.35 +/- 0.038 g/dL (mean +/- SE; P < 0.002). The increase was seen in patients both with and without diabetes. Thus, dialyzer membrane may affect serum albumin levels and should be considered in the differential diagnosis of hypoalbuminemia in patients undergoing hemodialysis with bioincompatible membranes. Membrane choice may have an important effect on the outcome of morbidity and mortality of hemodialysis patients.

A consortium-based research education program for residents

With growing pressures to consolidate and reorganize health care delivery systems, graduate medical education (GME) consortia can draw faculty from affiliated members to assemble educational programs. The authors report on consortium-based research education seminars of a quality that many residency programs would be unable to develop and support on their own. Drawing a diverse faculty from consortium members and area universities, the OHEP Center for Medical Education's annual Research Workshop Series focuses on the design of research projects; data analysis and hypothesis testing; and written and oral presentation of scientific research. Each spring, OHEP sponsors a research forum in which the best research projects from consortium members are presented by the resident-researchers, who compete for recognition and prize money. Further, of the 128 presentations made thus far at the annual OHEP Research Forum, 25% were subsequently published. The consortium's research education program has been well received by residents, is cost-effective, and is an integral component of the research curricula of many area residency programs. Including research training in GME provides residents an opportunity to become more competitive for fellowship, faculty, and leadership positions.

3-nitroadipate, a metabolic intermediate for mineralization of 2, 4-dinitrophenol by a new strain of a Rhodococcus species

The bacterial strain RB1 has been isolated by enrichment cultivation with 2,4-dinitrophenol as the sole nitrogen, carbon, and energy source and characterized, on the basis of 16S rRNA gene sequence comparison, as a Rhodococcus species closely related to Rhodococcus opacus. Rhodococcus sp. strain RB1 degrades 2,4-dinitrophenol, releasing the two nitro groups from the compound as nitrite. The release of nitro groups from 2,4-dinitrophenol occurs in two steps. First, the 2-nitro group is removed as nitrite, with the production of an aliphatic nitro compound identified by 1H nuclear magnetic resonance and mass spectrometry as 3-nitroadipate. Then, this metabolic derivative is further metabolized, releasing its nitro group as nitrite. Full nitrite assimilation upon reduction to ammonia requires that an additional carbon source be supplied to the medium.

Does exercise affect female hamster gonadotropins by reducing estradiol negative feedback?

Exercise stimulates reproductive function in hamsters exposed to short-day photoperiod (SDP) in contrast to its inhibitory effects in women and rats. SDP inhibits hamster reproduction in part by increasing the sensitivity of the hypothalamo-pituitary-gonadal axis (HPGA) to the negative feedback of gonadal steroids. To determine whether EX facilitates reproduction in female hamsters by affecting this mechanism, we examined the influence of estradiol (E2) on basal LH and FSH concentrations in exercising and sedentary hamsters maintained on long-day photoperiod (LD 14:10, LDP) or SDP (LD 8:16). In the LDP, serum LH and FSH were unaffected or reduced by exercise in ovariectomized (OVX) nonhormone-replaced hamsters, and LH was increased after tonic E2 replacement compared to sedentary controls. In the SDP, serum LH and FSH were significantly higher in OVX exercising than in sedentary hamsters, whether the exercisers were injected with a high dose of E2 or not. Thus, the effects of exercise on basal gonadotropin secretion in female hamsters appear to depend on the level of estradiol negative feedback (ENF). When this feedback is low (LDP OVX condition), exercise is either ineffective or inhibitory. When the ENF is increased by exposure to SDP and/or by treatment with E2, exercise has a stimulatory effect on basal gonadotropin secretion. Exercise may stimulate hamster gonadotropin secretion by reducing the ENF either by lowering the sensitivity of the HPGA to steroid negative feedback or by other means.

A new intermediate in the mineralization of 3,4-dichloroaniline by the white rot fungus Phanerochaete chrysosporium

Phanerochaete chrysosporium ATCC 34541 has been reported to be unable to mineralize 3,4-dichloroaniline (DCA). However, high mineralization is now shown to occur when a fermentation temperature of 37 degrees and gassing with oxygen are used. Mineralization did not correlate with lignin peroxidase activity. The latter was high under C limitation and low under N limitation, whereas the reverse was true for mineralization. The kinetics of DCA metabolism was studied in low-N and low-C and C- and N-rich culture media by metabolite analysis and 14CO2 determination. In all cases, DCA disappeared within 2 days, and a novel highly polar conjugate termed DCAX accumulated in the growth medium. This metabolite was a dead-end product under C and N enrichment. In oxygenated low-C medium and in much higher yield in oxygenated low-N medium, DCAX was converted to DCA-succinimide and then mineralized. DCAX was purified by high-performance liquid chromatography and identified as N-(3,4-dichlorophenyl)-alpha-ketoglutaryl-delta-amide by high-performance liquid chromatography and mass spectroscopy, gas chromatography and mass spectroscopy, and nuclear magnetic resonance spectroscopy. The formation of conjugate intermediates is proposed to facilitate mineralization because the sensitive amino group of DCA needs protection so that ring cleavage rather than oligomerization can occur.

The confirmation of a biochemical marker for women's hormonal migraine: the depo-estradiol challenge test

PRECIS

Will estrogen withdrawal cause migraines in post-menopausal women?

OBJECTIVE

To record the changes in serum estradiol and total estrogen levels after an intramuscular estradiol injection in menopausal subjects and then record any subsequent migraine occurrence.

DESIGN

Open selection process, comparative trial.

PATIENTS

Twenty-eight postmenopausal women volunteers were given 5 mg depo-estradiol cyprionate as an intramuscular injection. Sixteen (migraine group) had a history of severe, cyclic, menstrually related migraine attacks before becoming menopausal. Twelve (control group) had no history of migraine or headache. All volunteers were on continuous estrogen replacement therapy at the beginning of the study. Progestins were not used in the study.

MAIN OUTCOME MEASURES

Serum estradiol and total estrogen levels were measured prior to the depo-estradiol injection and on subsequent days 4, 7, 14, 21, and 28.

RESULTS

Total estrogen and estradiol levels varied greatly at every measured interval. Menopausal complaints of vasomotor symptoms were relieved for at least the first 2 weeks of the study. No member of the control group reported a migraine during the month. However, a severe migraine was reported by all 16 women with a history of migraine. The average day of the migraine occurrence was 18.5 +/- 2.8. The serum level of estradiol on the day of the worst migraine was 46.4 +/- 5.6 pg/mL. The significance of these findings was at the 95% confidence level.

CONCLUSIONS

This study confirms two factors about menopausal hormonal migraine: (1) it can be precipitated by a drop in serum estrogen levels, and (2) a period of estrogen priming is a necessary prerequisite. This study also identifies that there are two biologically different populations of postmenopausal women: (1) those who developed migraine after a single depo-estradiol injection, and (2) those who did not. By understanding that in addition to the biological predisposition to migraine there exists the biochemical cofactor of falling estrogen levels, we may better understand this phenomenon and develop means to prevent its occurrence.

Contraction rates of meshed, nonexpanded split-thickness skin grafts versus split-thickness sheet grafts

Contraction rates of wounds covered by meshed, nonexpanded split-thickness skin grafts were compared with split-thickness sheet-grafted wounds in a porcine model. No significant difference was found in wound contraction. When compared with previous studies, this study shows that differences in contraction previously observed were not a result of meshing and suggests that expansion may be the cause of the difference previously observed.

Molecular characterization of a cloned idiotypic cascade containing a network antigenic determinant specific for the human carcinoembryonic antigen

The monoclonal anti-idiotypic antibody (maId) 6G6.C4, directed against the carcinoembryonic antigen (CEA)-specific T84.66 immunoglobulin, was recently shown to act as a surrogate antigen for CEA in experimental animals. In this report, we have extended our studies. 1) The kinetics of complex formation in this CEA-specific idiotypic cascade were investigated using Biosensor technology. 2) Bacterial expression studies show that the mimicked epitope can be delimited to the A3 domain of CEA. 3) We cloned and characterized the genes coding for maId 6G6.C4. 4) Comparison of this epitope-bearing domain with the hypervariable region sequences of 6G6.C4 yields substantial amino acid similarity. Sequence homology between maId 6G6.C4 and anti-CEA antibodies binding to the T84.66 epitope led us to investigate the interaction of maId 6G6.C4 and CEA. Surprisingly, 6G6.C4 specifically binds to CEA but not CEA-related antigens in Western blots. 6G6.C4 and T84.66 recognize different epitopes on CEA. Our results suggest that the T84.66 epitope functionally mimicked by maId 6G6.C4 may be involved in the homophilic binding between CEA molecules, and that heterophilic interactions in the CEA-family are mediated by different binding sites. A model for the intermolecular adhesion of CEA is presented.

Ultrasound surveillance of the cervix in twin gestations: management of cervical incompetency

Fifty-one consecutive twin pregnancies studied prospectively were compared with 153 consecutive control twin gestations that were concurrently delivered, but chosen retrospectively. Study patients were managed by a protocol that used weekly ultrasound surveillance combined with clinical assessment. Control subjects were not managed by protocol or ultrasound surveillance. Seven of 51 study patients (13.7%) were diagnosed as having cervical incompetency before 30 weeks' gestation (range 18-28 weeks, mean 24). In comparison, 14 of 153 controls (9.2%) delivered before 30 weeks' gestation (range 18-29 weeks, mean 25). The mean cervical length, dilatation, and membrane herniation (funneling) at diagnosis were 1.9, 2.2, and 3.6 cm, respectively, for patients with cervical incompetency. There was a significant difference in perinatal mortality. All study twins survived, whereas nine control subjects delivered at a mean gestational age of 22.7 weeks, with a loss of 17 infants. Life table analysis demonstrated that a significantly greater proportion of controls delivered very low birth weight, premature twins. The use of ultrasound and clinical criteria to select patients for cerclage placement helped prevent birth of the youngest and smallest twins and significantly decreased perinatal mortality in the study group. Routine cerclage placement is not recommended for twin gestations, but multifetal gestations may benefit from ultrasound surveillance for cervical incompetency.

Toxicity of cleaning agents for removal of grease from wounds

Industrial injuries are often open wounds contaminated with grease. Commercial compounds used for removing grease from intact skin are composed of petroleum distillates. These products are occasionally used to remove grease from open wounds. Using an animal model, this study examines the use of commercial compounds in open wounds in comparison with mild detergent and water. A clear correlation is established between their use and adverse tissue reaction. The use of soap and water as opposed to petroleum-based compounds is recommended for removal of grease from a wound.

Complications of reduction mammaplasty: comparison of nipple-areolar graft and pedicle

A retrospective study of breast reductions in 268 patients by two plastic surgeons was performed. Particular attention was paid to those patients treated by inferior pedicle techniques; these patients were compared with those treated by free nipple grafts. According to our findings, patients with skin loss were heavier and had longer suprasternal notch-to-nipple distances. Patients who had free nipple grafts were older and heavier and had larger specimen weights and longer suprasternal notch-to-nipple distances. Fifty-four of the original 268 patients were included in a substudy of larger breasts, defined as those with a specimen weight of over 700 g. Nineteen patients underwent free nipple grafts, and 35 underwent inferior pedicle techniques. None of the 19 patients having free nipple grafts developed complications, whereas 6 of the 35 undergoing inferior pedicle techniques sustained significant complications. We conclude that free nipple grafts should be considered over inferior pedicles in heavier patients with breast ptosis.